Diagnostics
Due to the unspecific symptoms, gallbladder carcinoma is sometimes diagnosed by chance during a routine examination (e.g. abdominal sonography) of the abdomen. If a carcinoma of the bile ducts is suspected, the patient must first be questioned in detail (anamnesis). During this process, one must especially search for the symptoms that indicate a bile stasis.
Afterwards, the patient should undergo a thorough physical examination. The first thing that is often noticeable is a yellowing of the skin (icterus) and in some cases a painless, bulging gall bladder in the right upper abdomen can be palpated (Courvoisier ́sches sign). In advanced cases the actual tumor can even be palpated.
When analyzing the blood (laboratory), certain blood values may indicate a disease of the bile ducts. For example, gamma-glutamyl transferase (gamma-GT), alkaline phosphatase (AP) and billirubin may be elevated, which indicates a build-up of bile, but is not specific for gallbladder cancer. These blood parameters may also be elevated in other bile duct obstructions, such as a gallstone (cholecystolithiasis).
So-called tumor markers are substances in the blood that are frequently found in some types of cancer and can thus indicate the presence of cancer. They do not play a significant role in the initial diagnosis of gallbladder carcinoma, as false-positive results can often be obtained. If, however, a certain tumor marker value is found to be elevated before surgery, which disappears after surgery, then this marker can be used particularly well to diagnose a renewed outbreak of the tumor (tumor recurrence) by means of a rapid blood test.
Tumour markers that can be elevated in gallbladder cancer are CA 72-4, CA 19-9, CEA. Staging and grading Staging refers to the diagnostic procedure following the diagnosis of a malignant tumor. In addition to tissue examination (histology), staging plays a decisive role in the choice of therapy and the prognosis.
Staging assesses the spread of the tumor in the organism. Grading is also performed as part of staging. Here, the tumor cells are classified according to their differentiation.
Differentiation in this case refers to the extent to which the cells from the biopsy obtained match the cells from which they originated. SonographySonography (ultrasound) is a non-invasive method of assessing abdominal organs without the use of radiation. With sonography of the abdominal cavity (abdomen), the extent of the tumor in the gallbladder bed, the extent of bile duct narrowing and affected lymph nodes in the abdominal cavity can be assessed.
Since the method is easy to use and not stressful for the patient, the sonography can be repeated as often as required and can be used especially for follow-up and aftercare. Computed tomographyComputer tomography (CT) produces tomographic images using X-rays and can provide information about the extent of the tumor, its spatial relationship to neighboring organs (infiltration), lymph node involvement and also about distant metastases. It is not uncommon to need a CT scan of both the chest (thorax) and the abdomen to assess all metastatic pathways (liver and lung).
Similar results are obtained with magnetic resonance imaging (MRI) and an MRI of the liver. Endoscopic retrograde colangiopancreatectomy (ERCP)In this examination method, an endoscope with lateral view optics (duodenoscope) is advanced to the duodenum and the major duodenal papilla (papilla Vateri, father ́sche papilla) is probed. This is the opening of the common duct of the liver, gallbladder (ductus coledochus) and pancreas (ductus pancreatica).
If it is not possible to advance the instruments into the bile duct, it is necessary to carefully cut open the papilla opening to widen the opening. This procedure is called papillotomy or sphincterotomy. In the second step of the examination, contrast medium is injected into these ducts against the flow direction of the digestive juices (retrograde).
During the injection of the contrast medium, an X-ray image of the upper abdomen is taken. The contrast medium thus makes narrowing of the ducts (stenoses), caused by gallstones or tumors, visible and thus assessable.In addition, it is possible to take a tissue sample from the tumor (biopsy) through the endoscope and have it examined histologically by the pathologist under the microscope. During the ERCP, therapy can be performed in the same session.
For example, it is possible to remove a stone with an inserted instrument or, in the case of constrictions caused by tumors or inflammations, to restore the flow of bile and/or pancreas by inserting a plastic or metal tube (stent). Percutaneous transhepatic cholangiography (PTC)If the visualization of the bile ducts using ERCP is unsuccessful, percutaneous transhepatic cholangiography can be performed. In this method, the liver is punctured with a hollow needle through the skin and a bile duct is located.
As in ERCP, a contrast medium is injected to show the bile ducts on an x-ray. It is also possible to use this method to drain the bile fluid to the outside via a so-called percutaneous transhepatic drainage (PTD) in order to eliminate a backlog in the bile ducts. Especially in the case of inoperable tumors, this can provide relief in cases of severe jaundice.
Chest x-ray: A chest x-ray (chest x-ray) is taken to provide information about a metastatic infection of the lung. Endosonography (endoluminal ultrasound) In endosonography, as in gastroscopy (esophago-gastro-duodenal endoscopy), a tube is first inserted into the duodenum in the immediate vicinity of the tumor. However, in this examination, an ultrasound probe is placed at the end of the tube instead of a camera.
With this method, the spread of the tumor in depth (infiltration) can be visualized by placing the ultrasound probe on the tumor and (regional) lymph nodes in the vicinity of the gallbladder can also be assessed. Laparascopy: In advanced tumor stages, it is sometimes necessary to perform a laparoscopy in order to correctly assess the regional extent, abdominal cavity infestation (peritoneal carcinosis) and liver metastases. During this procedure, which is performed under general anesthesia, various instruments and a camera can be inserted through incisions in the abdominal skin, allowing the tumor spread to be observed.
